Inspection on 11/10/06 for Cedar Avenue

This inspection was carried out on 11th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Cedar Avenue 20/05/08

Cedar Avenue 23/05/07

Cedar Avenue 10/02/06

Cedar Avenue 18/07/05

Cedar Avenue 10/03/05

Cedar Avenue 29/06/04

Cedar Avenue 23/02/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

Pennine Camphill

Muston Road (70)

Grayling

The Cornerstone

John Street Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Cedar Avenue 5 Cedar Avenue Edgerton Huddersfield West Yorkshire HD1 5QH Lead Inspector Jacinta Lockwood Unannounced Inspection 11th October 2006 12.40 Cedar Avenue DS0000026335.V315866.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Cedar Avenue DS0000026335.V315866.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Cedar Avenue DS0000026335.V315866.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cedar Avenue Address 5 Cedar Avenue Edgerton Huddersfield West Yorkshire HD1 5QH 01484 530300 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) None United Response Ms Leanne Victoria Joseph Care Home 4 Category(ies) of Learning disability (4), Physical disability (4) registration, with number of places Cedar Avenue DS0000026335.V315866.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th February 2006 Brief Description of the Service: Cedar Avenue is registered to provide personal care and accommodation for up to four male and female adults aged 18-65 with a learning disability and physical disability. The registered provider is United Response. The purpose-built bungalow style accommodation is located in a residential setting within walking distance of Huddersfield town centre and local amenities. There is car parking available. The home is staffed twenty-four hours a day and there is one wakeful night staff member and one member of staff sleeping in on the premises. An on-call system is also in operation. The Commission were informed that as at 14.08.06 the weekly fee was £1662.86 per week. Information about the home in the form of a Service User’s Guide and Statement of Purpose, together with the most recent Commission for Social Care Inspection report are available at the home. Cedar Avenue DS0000026335.V315866.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. As part of this inspection, one inspector made an unannounced visit to the home on 11.10.06, starting at 12:40 and ending at 20:20 hours. During the site visit, the inspector met all four of the people living at the home, who owing to their disabilities were unable to express their views about life at the home but who, from observation, appeared to be well supported by staff. Prior to this visit, questionnaires were sent out to obtain the views of service users, relatives, GPs and health and social care professionals. Surveys were sent to the people living at the home, three of which were completed and returned by staff on behalf of the people they support. Surveys were also sent to service users’ next of kin; two were returned; GPs, none were returned; and social and health care professionals, three were returned. A pre-inspection questionnaire was also completed by the home’s registered manager and returned to the Commission before the visit. The inspection findings are also based on a range of accumulated evidence received by CSCI since the last inspection, including, for example, notifiable incident reports when service users are involved in an accident or incident and the service quality review report. The care records of two service users were inspected, including care plans, risk assessments, medication, any monies and accounting records held by the home. Other records inspected included the food menu, staffing rota, staff recruitment and training records and some policies and procedures. A partial tour of the building was made, including the bedrooms of two service users. The inspector would like to thank all those who contributed to the inspection process. What the service does well: The service has a well trained and motivated staff team who are committed to providing a good quality of service to the people they support at Cedar Avenue. Service users, who looked well cared for, appeared relaxed and comfortable with staff. Staff interacted with service users in a calm manner, explaining what they were doing and seeking service users’ understanding of what was happening. Cedar Avenue DS0000026335.V315866.R01.S.doc Version 5.2 Page 6 Staff support service users to access community based facilities using public transport. And service users are supported to engage in a range of social, educational and household activities. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Cedar Avenue DS0000026335.V315866.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Cedar Avenue DS0000026335.V315866.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Prospective service users’ individual needs are assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There has been one new admission to the home since the last inspection in February 2006. A community care assessment was obtained prior to admission. Staff from the home also carried out a pre-admission assessment. However, the home’s assessment documentation had not been dated or signed so as to make clear when this was completed or by whom. (See Recommendations.) Assessment information formed the basis of the service user’s support plan. It was evident from records and discussion with staff that the service user was supported to make visits to the home before moving there to give the service user an opportunity to meet the other service users and staff and to see the home. The service user also received a copy of the home’s service user’s guide. Cedar Avenue DS0000026335.V315866.R01.S.doc Version 5.2 Page 9 A statement of terms and conditions signed by the registered manager was on file as evidence that the home could meet the service user’s needs. But this had not been signed or dated on behalf of the service user even though there was space to do so. (See Recommendations.) This was the first, new admission to the home since it originally opened. From discussion with staff it was evident that they found it a “learning experience” which had its difficulties. Staff felt they lacked management support during this time and that strategies to support the service user and staff following the admission were lacking. Staff explained that they have had an opportunity to discuss their concerns during this time with management. Cedar Avenue DS0000026335.V315866.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Not all service users’ assessed and changing needs and personal goals are reflected in their individual plan. Service users make decision about their lives with assistance. Service users are supported to take risks as part of an independent lifestyle. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Two service users’ records were examined and the findings discussed with the home’s registered manager. Within the records there was a good level of information but relevant information was not always included within the service users’ support plans, which lacked specific detail and in some instances, did not include advice given by healthcare professionals. And, although it was evident from discussion with staff that they were aware of the service users’ Cedar Avenue DS0000026335.V315866.R01.S.doc Version 5.2 Page 11 support needs, for example, support with meals, this information was not recorded in the plan of support. The registered manager had informed the inspector, prior to the visit, that a specific support plan was to be put in place for one of the service users whose care records were examined as part of this inspection, but this plan was not available at the time of the visit. Short-term support issues, for example, with regard to a chest infection and sore areas on the service users’ body did not have a support plan in place. Potential risks identified on a service user’s assessment record had not been fully risk assessed nor planned for. Risk assessments for a range of individual risks were seen within service users’ files. A support plan had not been dated, to notify the reader of its currency, nor signed by the person completing the plan, or by the service user’s representative to indicate agreement with the plan. One of the plans seen was written in the first person, noting the service user’s preferences for care delivery. There were gaps in daily reporting and not all entries had been signed. It was not possible to tell from records whether or not some issues identified in the daily report had been followed through. Requirements and recommendations regarding record keeping are made within this report. Records and discussion with staff indicate that service users receive sensitive and flexible personal support to maximise service users’ privacy, dignity, independence and control over their lives. Staff were observed to offer service users choice regarding food, drink, activity and where to spend time within the home. Whilst doing so, staff promoted service users’ independence, showing respect and maintaining people’s dignity. Aids and equipment are available at the home to maximise service users’ independence. Records show that, generally, equipment is regularly maintained. Relatives’ surveys indicate that they are satisfied with the overall care provided at the home. Cedar Avenue DS0000026335.V315866.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Service users are supported to take part in age, peer and culturally appropriate activities within the local and wider community. Opportunities are provided for service users to engage in social and leisure activities and to maintain and develop relationships with family and friends. Service users’ cultural dietary needs are met and a well balanced diet provided. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. EVIDENCE: From records and discussion with staff it is evident that service users are able to take part in age, peer and culturally appropriate activities within the local and wider community. ‘Active Support Timetables’ are in place which show the social, educational and household activities in which service users take part. The timetables also ensure that service users have some predictability and Cedar Avenue DS0000026335.V315866.R01.S.doc Version 5.2 Page 13 consistency in their lives. Staff time with and support for service users outside the home is flexibly provided and includes evenings and weekends. Service users go on holiday with support from staff and DVDs and brochures are used to help service users choose where they would like to go. Holidays are usually on an individual basis. Service users have bus passes and are supported to use public transport and community based facilities such as banks, post offices, shops, cafes, bars, clubs, restaurants and the cinema. Service users also have opportunities to meet and make friends at social clubs and day and educational centres. Sensory equipment is available within the home and service users have access to music, television and a computer. Staff explained that relatives are involved and service users are supported to maintain family contact through visits. It was evident from discussion with staff and records that the home values and seeks to reflect the racial and cultural diversity of service users. Service users are supported by staff and relatives to fulfil their spiritual needs and to take part in religious and family festivals. From records, observation and discussion it’s evident that service users have access to a well-balanced diet. Service users are involved in shopping for food. Cultural dietary needs are met and separate food storage areas provided for Halal products. Cedar Avenue DS0000026335.V315866.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Generally, service users’ health care needs are met by staff and relevant professionals, but omissions in record keeping pose a potential risk to service users. Generally, service users receive personal support in a flexible manner that meets their needs. There is a lack of attention to detail regarding medication records which could pose a risk to service users. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Records and discussion with staff indicate that service users receive sensitive and flexible personal support to maximise service users’ privacy, dignity, independence and control over their lives. But gaps in record keeping have a potential to place service users at risk. (This is addressed under the section on Individual Needs and Choices.) Cedar Avenue DS0000026335.V315866.R01.S.doc Version 5.2 Page 15 Service users, who are fully dependent on staff for personal and healthcare support, were well groomed and looked well cared for. Aids and equipment are available at the home to maximise service users’ independence. From records and discussion with staff it’s evident that care staff receive manual handling training to ensure that service users are moved and handled in a safe manner. There was evidence of healthcare input. Healthcare professional surveys noted that although there was good initial contact and joint working, not all staff at the home took on board the information given and follow-up contact needed prompting. Evidence to support this was seen within records examined during this visit. (See Recommendations.) However, healthcare professionals’ surveys indicate that they are satisfied with the overall care provided at the home. Owing to their high dependency needs, none of the service users self-medicate and staff administer service users’ medication. Two samples were checked. There was evidence that medication is kept under review. Medication entered into stock and stock carried forward was not always recorded on the medication administration record (MAR) sheet. This prevents stock reconciliation. There were some gaps in recording the administration of medicines. Staff must sign the record sheet at the time of administration and ensure there is a clear audit trail. (See Requirements.) The inspector spoke with the organisation’s NVQ Assessor during the visit who explained that medication training had recently been provided to staff during which action points to improve practice, for example, in relation to recording, had been identified and would be addressed. A medication policy and procedure is available as is information on the types of medication used at the home. Cedar Avenue DS0000026335.V315866.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Service users can be confident that their views would be listened to and acted upon. Service users are protected from abuse, neglect and self-harm. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home’s complaints procedure is available in print and symbol format for service users who each have a copy. No complaints have been received by the home. Two relatives’ comment cards received indicated that they were unaware of the home’s complaints procedure but that they had never had to make a complaint. The home’s complaints procedure is included in the home’s statement of purpose and service user’s guide. Two samples of service users’ monies were checked and reconciled with records held. Monies are stored securely. Receipts are kept and monies are audited by two staff and double signed. The home has a whistle blowing and adult protection policy and procedure. The registered manager was informed during the visit that the local authority adult protection policy and procedure had recently been re-launched and that the home’s procedure should be reviewed in light of this. (See Recommendations.) Cedar Avenue DS0000026335.V315866.R01.S.doc Version 5.2 Page 17 Staff receive adult protection training and staff spoken with gave good responses to questions asked about adult protection. It was evident from observation and discussion with staff that they take appropriate action where a service user was placed at potential risk from selfharm. Cedar Avenue DS0000026335.V315866.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Not all areas of the home provide a homely, comfortable and safe environment for service users. Not all areas of the home were clean and hygienic. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Cedar Avenue was purpose built and is in keeping with the local community. There is level access to the home and grounds. The home offers access to local transport, local amenities and relevant support services. The home provides a communal lounge and dining/kitchen area plus single bedroom accommodation. An overhead tracking system is in place between a bathroom adjoining two bedrooms. This has benefits for the service users concerned, as it means they are involved in fewer transfers using moving and handling equipment. Cedar Avenue DS0000026335.V315866.R01.S.doc Version 5.2 Page 19 Service users who are able were seen to move freely between their private and communal spaces. Bedrooms seen were equipped to meet service users’ needs. It was evident from observation that the home is in need of some maintenance work to ensure that the environment in which service users live is safe, comfortable and homely. Although some redecoration of the home has taken place, the quality of the work in some areas, gives the home an uncared for appearance. The kitchen furniture is dated and some cupboard/drawer fronts were missing. Unsightly staining was obvious to a cupboard surface facing the dining area. Water damaged hallway-flooring poses a potential tripping hazard. The registered manager explained that the hallway flooring was to be replaced. (See Requirements.) The shower room had an unpleasant odour. And there was staining to tiles, particularly around the grouting. Wood enclosing a sink pedestal was splitting. Wood panelling to a bath had a piece missing. Action must be taken to address this to ensure that hygiene standards are maintained to an acceptable level. (See Requirements.) The garden at the rear of the property was overgrown and in need of maintenance. (See Requirements.) These outstanding maintenance issues do not contribute to a safe, comfortable or homely environment for service users. (See Requirements.) Laundry facilities are provided away from food areas. The laundry area was untidy with debris on the floor and mops in the sink. Action must be taken to ensure that hygiene standards in the laundry room are maintained to an acceptable level. (See Requirements.) The home’s annual quality assessment report also noted that environmental improvements were necessary. Cedar Avenue DS0000026335.V315866.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 There is a good staff training and development programme in place, which ensures that staff fulfill the aims of the home and meet the changing needs of service users. Service users are supported and protected by the home’s recruitment practices. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: It was evident from discussion with staff and records that relevant training is provided to ensure that staff have the knowledge and skills necessary to support people living at Cedar Avenue. Staff appeared enthusiastic and motivated to provide support in a person centred way and explained that individual support is provided so that service users can engage in social and leisure activities, which they enjoy. Cedar Avenue DS0000026335.V315866.R01.S.doc Version 5.2 Page 21 Staff spoke positively about the range of training provided by the organisation. Staff and the registered manager also explained that movement and handling and challenging behaviour training specific to individual service users had been arranged. Staff were observed to approach service users in a skilled, calm and caring manner and service users appeared comfortable with staff, smiling and making eye contact. Written information received by the Commission on 16.08.06 from the registered manager, noted that one of the twenty support staff employed to work at the home has a National Vocational Qualification (NVQ) to Level 2 or above. During the visit, the organisation’s NVQ Assessor was visiting with a member of staff to progress NVQ work. The NVQ Assessor reported that two staff have now completed this award. Whilst this is positive, progress needs to be made in this area so that a minimum level of 50 of staff hold this qualification as recommend in the National Minimum Standards for Younger Adults. (See Recommendations.) Two staff recruitment files were examined and all required information had been obtained to ensure that only those people suitable to work with vulnerable people are employed. Staff spoken with confirmed the recruitment process. Although it is good practice and not a requirement under The Care Homes Regulations 2001, the home’s own recruitment procedure notes that Criminal Record Bureau checks should be repeated every three years. Records show that some CRB checks are overdue for renewal to evidence that staff currently employed continue to be suitable to work with vulnerable adults. (See Recommendations.) Cedar Avenue DS0000026335.V315866.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 An apparent lack of management oversight at the home means that the home is not well run at present. Although an annual review of the service is conducted to ensure that the home is run in the best interests of service users, there is a lack of evidence to show that areas identified for improvement have been fully actioned. Although generally, the health, safety and welfare of service users are promoted and protected, some shortfalls pose a potential risk to service users. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Cedar Avenue DS0000026335.V315866.R01.S.doc Version 5.2 Page 23 EVIDENCE: Leanne Joseph, who is the registered manager for Cedar Avenue, explained that she is continuing to work towards the Registered Manager’s Award. A recommendation regarding completion of the award is made within this report. The organisation’s management structure has undergone changes recently, which, potentially, has implications for the management of the care home. It was not possible to establish from staffing rotas, the number of hours the registered manager spends at the home, but discussion with her indicates that this is three days’ a week and that she always spends the morning at the home. The registered manager’s hours must be recorded on the staffing rota as required by legislation and a requirement is made regarding this. (See Requirements.) Discussion with some staff indicated that they tell each other if things within the home are not being done. But that, since the management restructure, they feel no one has overall responsibility for the home. Staff also reported that morale at the home had been low, but that this had improved. It’s evident from the findings of this visit and as noted throughout this report that some standards at the home have dropped since the time of the last inspection in February 2006. The registered manager acknowledged this. Both the registered manager and the responsible individual for the service must ensure that the home is well run and that action is taken to operate the home within legislative requirements and good practice recommendations. (See Requirements.) An annual review of the service is conducted to ensure that the home is run in the best interests of service users. An annual report, dated 29.03.06, based on observation of communication between service users and staff and records, has been provided to the Commission. The report notes that some excellent pieces of work have taken place with individual service users and also, some areas for improvement, for example, the environment and record keeping. The views of service users’ next of kin and of any professionals involved with service users were not sought as part of this annual review. Their views should be sought regarding the quality of the service provided at the home so that service users can be sure that the home is run in their best interests. (See Recommendations.) Monthly management reports required under Regulation 26 of The Care Homes Regulations 2001 have not been supplied to the Commission for some time and a requirement is made for these to be supplied so that the Commission can monitor any improvements made within the service. (See Requirements.) Cedar Avenue DS0000026335.V315866.R01.S.doc Version 5.2 Page 24 A sample of health and safety documentation was examined. These show that staff are involved in fire safety drills and that fire safety equipment is checked on a regular basis. The registered manager explained that she has received competent person fire safety training and that fire safety training for staff has been arranged for 24.10.06. A sample of maintenance certification shows that equipment is serviced as required, although servicing of the overhead tracking system was overdue. This must be addressed so that service users are not placed at unnecessary risk. (See Requirements.) Wheelchairs were being stored in such a position that access to the rear door was impeded. This poses a potential fire safety hazard. (See Requirements.) Accidents and incidents are recorded. However, not all have been notified to the Commission as required by legislation. (See Requirements.) Although water at the point of delivery should not exceed 43 degrees Celsius, so as to prevent a risk of scalding during whole body immersion, bath temperature records show a temperature range of between 36-39 degrees Celsius. Appropriate advice should be sought and action taken regarding this, as bath water temperatures appear to be too low at times. This was also noted during the last inspection of the home. (See Recommendations.) Cedar Avenue DS0000026335.V315866.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 2 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 X 28 X 29 X 30 1 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 1 x 1 X 2 X X 1 X Cedar Avenue DS0000026335.V315866.R01.S.doc Version 5.2 Page 26 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15(1) Requirement Service users’ support plans must: provide specific and detailed information, including any advice given by healthcare professionals and identified in assessment documentation so that staff providing care and support have full information. The medicines administration record must be completed whenever medication is administered to a service user, so that there are no gaps in recording. (Timescales of 17.11.04, 31.08.05 and 10.02.06 not met). Medication received into the home must be recorded on the medicines record to aid stock reconciliation. Timescale for action 24/11/06 2. YA20 13(2) 24/11/06 3. YA24 23(2)(b)(d)(o) Maintenance work identified 22/12/06 in the body of this report must be addressed so that, both internally and externally, a safe, comfortable and homely environment is provided to service users. DS0000026335.V315866.R01.S.doc Version 5.2 Page 27 Cedar Avenue 4. YA30 23(2)(d) 5. YA37 17(2) Schedule 4(7) 10(1) 6. YA37 7. YA39 26 8. YA42 13(5) 9. 10. YA42 YA42 23(4)(b) 37 Standards of cleanliness in the shower and laundry areas must be improved so that service users are not placed at unnecessary risk. The hours worked at the care home by the registered manager must be recorded on the staffing rota. The registered manager and the responsible individual must take action to address breaches of regulation identified in this report. Management reports required under Regulation 26 of The Care Homes Regulations 2001 must be supplied to the Commission. The overhead tracking system in use at the home must be serviced as required to ensure that service users are not placed at unnecessary risk. Wheelchairs must not impede fire exit points. All accidents and incidents must be reported to the Commission as required under Regulation 37 of The Care Homes Regulations 2001. 24/11/06 24/11/06 22/12/06 24/11/06 24/11/06 24/11/06 24/11/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA1 Good Practice Recommendations The home’s pre-admission assessment documentation should be signed and dated by the person completing the assessment. Cedar Avenue DS0000026335.V315866.R01.S.doc Version 5.2 Page 28 2. 3. YA1 YA6 4. 5. YA19 YA20 6. 7. YA23 YA23 8. 9. YA32 YA34 10. YA35 The service user, where able, or their representative should sign the home’s statement of terms and conditions. Daily records should be fully completed, signed and dated, to evidence delivery of the care and support identified within the service users’ support plan and whether this is meeting service users’ needs. Staff should ensure that they act on advice received from healthcare professionals and that they maintain contact with them as appropriate. The registered person should ensure that staff authorised to administer rectal diazepam sign the GP authorisation sheet. (This was not assessed during the visit on 11.10.06 and will be checked during the next inspection of the service.) The home’s procedure regarding the protection of vulnerable adults should be reviewed in light of the recent re-launch of the local authority adult protection procedure. An in-house procedure for current practice in relation to the handling of service users monies and valuables should be available to staff and for inspection purposes. (This was not checked during the visit on 11.10.06 and will be checked during the next inspection of the service.) 50 of care staff should achieve NVQ level 2 training or equivalent. Criminal Record Bureau checks should be carried out every three years for staff currently employed at the home in accordance with the home’s recruitment policy and procedure. Disabled trainers should provide disability equality training to staff. (This was not assessed during the visit on 11.10.06 but will be assessed during a future inspection of the service.) The home’s registered manager should complete the Registered Manager’s Award. The views of service users’ relatives and any professionals involved in their care should be sought as part of the home’s annual quality review. Appropriate advice and action should be taken regarding bath/shower water temperatures, as these appear low. 11. 12. 13. YA37 YA39 YA42 Cedar Avenue DS0000026335.V315866.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Cedar Avenue DS0000026335.V315866.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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